
<div class="form-group">
<div class ="container">
<form class="form-horizontal" role="form" action="<?php echo site_url('stop/input_form');?>" method="post">
<label>NIK Pemegang Kartu Stop</label>
<input required class="form-control" id="nama" type="text" name="nama" maxlength="50" value="" ></br>
<label>Tanggal</label>
<input class="form-control" id="-datepicker" type="text" name="tanggal" maxlength="50" value="<?php echo date("Y-m-d"); ?>" readonly required ></br>
<label>Jam</label>
<input class="form-control" id="-time" type="text" name="jam" maxlength="50" value="<?php echo date("H:i:s"); ?>" readonly required ></br>
<label>Lokasi </label>
<input required class="form-control" id="lokasi" type="text" name="lokasi" maxlength="50" value="" ></br></br>
<!--<label>Departemen </label>
<input required class="form-control" id="departemen" type="text" readonly name="departemen" maxlength="50" value="<?php echo $this->session->userdata('departemen'); ?>" required ></br></br>-->
<table>
<tr>
<td>Kondisi Tidak Aman <input required class="form-control" id="aman" name="aman" type="radio" class="" value="1" /></td>
<td>Tindakan Tidak Aman <input required class="form-control" id="aman" name="aman" type="radio" class="" value="2" /></td>
</tr>
</table>
</br></br></br>
<label>Deskripsi Singkat Kejadian</label>
<textarea rows="5" required class="form-control" id="ling" type="textarea" name="desc" maxlength="500" value=""></textarea>
<label>Rekomendasi</label>
<textarea rows="5" required class="form-control" id="ling" type="textarea" name="rec" maxlength="500" value=""></textarea></br></br>
<table>
<tr>
<td colspan="2"><center>REKOMENDASI TELAH DIJALANKAN</center></td>
</tr>
<tr>
<td>YA<input required class="form-control" id="aman2" name="aman2" type="radio" class="" value="1" /></td>
<td>TIDAK <input required class="form-control" id="aman2" name="aman2" type="radio" class="" value="2" /></td>
</tr>
</table></br></br></br>
 
		Nama Pelanggar     </br>
        <input required class="form-control" id="nama1" type="text" name="nama1" maxlength="50" value="" />
        <!--<input required class="form-control" id="nama2" type="text" name="nama2" maxlength="50" value=""/>-->
</br></br>
		<!--Pengawas Telah Memvalidasi
		<input required type="checkbox"></br></br>-->
		<input required type="submit" class="btn btn-primary" value="Kirim"/>
</div>
		</form>
		</div></body></html>